Howard Dean is annoyed. He wants his own arguments to be evaluated on their merits, regardless of where he works these days. “I do work part-time for a law firm. And a law firm has clients,” he told TIME on Monday, after publishing a Wall Street Journalop-ed criticizing a key part of ObamaCare. “I dare say some of the clients think [the op-ed] is great, but I don’t write stuff because the clients like it. I write stuff because I believe it.”

Dean’s critics are not so sure. The Journal piece praised Obamacare but condemned a controversial cost-control board created by the law, the Independent Payment Advisory Board (IPAB). Supporters of the law, mostly on the left, charged that Dean, far from an independent observer of health care policy, is a shill for various elements of the health care lobby.

Jonathan Cohn, a health care writer for The New Republic, accused Dean of writing his op-ed on behalf of Big Pharma. Writes Cohn:

Since his career in politics ended, Dean has found a home in the K Street establishment he once held in such disdain. He’s a strategic adviser to McKenna, Long, and Aldridge, a major Washington lobbying firm whose clients have included health care and pharmaceutical companies. Dean has never registered as a lobbyist, as far as I know, but the distinction is largely illusory. In 2009, one CEO told the publication BioCentury that Dean was “very helpful” in their efforts to loosen federal regulations on drug development.” Another said that “Dean has been a great addition to our team.”

It looks like he still is.

Jonathan Chait, of New York magazine, was no kinder to Dean. Writing under the headline, “Howard Dean, Concerned American and Non-Shill,” Chait wrote:

Dean’s op-ed notes his affiliation in the tagline, but it doesn’t say what his clients think about IPAB. For that matter, Dean has refused to disclose which firms he’s representing on behalf of McKenna Long & Aldridge. It seems to be regular practice at the Journal editorial page to let retired Democrats lobbying for the health-care industry write op-eds calling for a repeal of parts of the law that reduce the industry’s profit margin.

Indeed, Dean’s work for McKenna, Long and Aldridge (MLA) has cast a long shadow over his public health care views—especially when they seem to run counter to his previous public stances. Dean was a huge supporter of health care reform’s ill-fated “public option,” a government-run insurance plan that would have competed with private insurers and which was beloved by liberals. IPAB, which Dean wrote in his Journal op-ed should be eliminated, is another Obamacare provision favored by liberals. The board would be charged with keeping Medicare spending growth within certain parameters, tied to inflation. If Medicare spending grows too fast, IPAB will be empowered to reduce Medicare reimbursements to physicians.

Dean says IPAB is a “rate-setting” board that would ration care by reducing Medicare physician reimbursements so drastically certain medical services would no longer be available. “If you had to go see a physician and make some complicated decisions about a serious illness, would you want a board in Washington making the decisions about what you could have and couldn’t or would you rather have your physician making those decisions?” asks Dean.

One of the most powerful interest groups vehemently opposed to IPAB is the American Medical Association. Asked if he wrote his Journal op-ed on behalf of the AMA or MLA clients, Dean said, “To the best of my knowledge the AMA is not a client of our firm. “ (MLA did not return a request for comment about its client list.) Deans says he is paid a flat annual fee by MLA for “giving political advice to whoever wants it.”

And does MLA have clients who dislike IPAB? “I’m sure we do,” says Dean. “What annoys me is that everything you say comes down to who’s paying you to say it. You can talk like that if you want to but I don’t think it helps the general discussion. We ought to argue on the merits.”

> “What annoys me is that everything you say comes down to who’s paying you to say it."

Well, Governor, it does. You're either shilling it for someone paying you or swimming in their pool, soaking in it. Either way, it's not odd to mention your affiliations, considering how what you're saying now seems to run counter to your earlier position. Complaining that the question is being asked is a poor way to shut down opposing debate.

> "We ought to argue on the merits."

Sure, lets.

Compare this, from your WSJ op-ed:

"One major problem is the so-called Independent Payment Advisory Board.
The IPAB is essentially a health-care rationing body. By setting doctor
reimbursement rates for Medicare and determining which procedures and
drugs will be covered and at what price, the IPAB will be able to stop
certain treatments its members do not favor by simply setting rates to
levels where no doctor or hospital will perform them."

"It’s fairly common knowledge at this
point that Congress does not allow Medicare to negotiate with
pharmaceutical companies over the amount the government pays for their
drugs. Each drug company simply sets a price for its own product, and
Medicare either takes it or doesn’t. While that arrangement undoubtedly
drives up Medicare spending—and health care spending more generally—it
at least allows for some competition among the drug companies that
manufacture similar products. But when it comes to paying doctors for
the services and procedures they perform, the system is even more
backward. In this case, Medicare actually asks the suppliers—the doctors
themselves—to get together first, compare notes, and then report back
on how much each of them ought to get paid.

Medicare is not legally required to accept the RUC’s recommended
values for doctors’ services and procedures, but the truth is, it
doesn’t have much of a choice. There is no other advisory body currently
capable of recommending alternative prices, and Congress has never
given the CMS the resources necessary to do the job itself.

The consequences of this set-up are pretty staggering. Allowing a
small group of doctors to determine the fees that they and their
colleagues will be paid not only drives up the cost of Medicare over
time, it also drives up the cost of health care in this country writ
large. That’s because private insurance companies also use Medicare’s
fee schedule as a baseline for negotiating prices with hospitals and
other providers. So if the RUC inflates the base price Medicare pays for
a specific procedure, that inflationary effect ripples up through the
health care industry as a whole.

Another, even more powerful consequence of this system is that while
the prices Medicare and private insurers pay for certain procedures have
increased—sometimes rapidly—the prices paid for other services have
declined or stagnated. That’s largely because of basic flaws in the way
the system is set up. For one, the RUC spends the vast majority of its
time reviewing specialty procedures, which change more quickly as
technology advances, rather than so-called 'cognitive' services, like
office visits, that primary care doctors and other generalists rely on
for the bulk of their income. The result is that there are “a hundred
ways to bill for removing varicose veins, and only one way to bill for
an intermediate office visit,” one former RUC member told me. For
another, the RUC is dominated by specialists, who have a direct interest
in setting the reimbursement rates for specialty procedures much higher
than for general services."

Now, I take issue with your assertion that the IPAB is "essentially a healthcare rationing body." Limiting the universe of available options is not in essence "rationing" in that we're not talking about denying treatment...only that Medicare won't be giving a blanket approval to pay for any and all procedures and pharmaceuticals. The purpose of the IPAB is to recommend* treatments that are effective both cost- and health-wise. It's to keep doctors from ordering procedures that maximize their own profitability while costing taxpayers more and indirectly driving up costs for the insured.

It's to return control of healthcare spending back to the people. Or people in Congress, at least. Fixing what's wrong there is another topic.

(*can be overridden by Congress; personally, I'd prefer if there were more stringent cost controls in place and that the IPAB actually had teeth to go along with its bark)

Actually, I did realize that question could be asked of me as well, even if it was directed specifically to Dean. I don't swim in the same waters he does, not even in the same ocean.

I really don't know what the response is, other than that I'm not affiliated with any org that has a dog in this hunt and I don't get paid to advocate or lobby, as Governor Dean is. I've never ran away from being called a liberal or lefty, but if that can be considered a 'pool', I'm sitting on the edge of the shallow end, cooling off my feet.